Chapter 10 TACTICAL FIELD SKILLS for the MILITARY PHYSICIAN

Tactical Field Skills for the Military Physician

Chapter 10 TACTICAL FIELD SKILLS FOR THE MILITARY PHYSICIAN

SEAN MULVANEY, MD,* and TONY S. KIM, MD†

INTRODUCTION

THE PROBLEM AND NEED FOR TRAINING

SHOOT Weapons Training Combatives

MOVE Principles of Navigation Driving Military Vehicles Convoy Operations Personal Equipment and Moving

COMMUNICATE

ADDITIONAL OPERATIONAL MEDICAL TRAINING Flight Medicine Dive Medicine Airborne Survival, Evasion, Resistance, Escape

OTHER CONSIDERATIONS Military Bearing Medical Evacuation and Mass Casualty Planning and Training Preventive Medicine Operational and Intelligence Briefings Time Management

SUMMARY

*Colonel (Retired), Medical Corps, US Army; Associate Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland †Colonel, Medical Corps, US Air Force; Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

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INTRODUCTION

There are two compelling reasons for military phy- skills must be performed, and becoming proficient in sicians to learn and hone the basics of military combat them takes time, in some cases years. Although these skills. The first is that the physician must never be a skills may never be used in combat, they are worth liability for the supported unit. The second is that by learning and will increase the physician’s ability to fundamentally understanding the demands of the both care for and relate to patients. Although the easi- unit’s mission-essential tasks, the physician is better est time to learn these skills is early in one’s career, it able to interpret injury patterns and set reasonable is never too late to begin and it is always appropriate return-to-duty requirements and limitations. In ad- to review and refresh these skills on a regular basis. dition, learning these skills establishes a set of shared Vice Admiral Joel Boone is arguably among the best experiences that facilitate effective communication examples of a combat physician. This is his Medal of between physician and patient. Honor Citation from World War I: At its core, soldiering skills consist of being able to safely and effectively shoot, move, and communicate. For extraordinary heroism, conspicuous gallantry, Each of these basic tasks has a series of implied tasks. and intrepidity while serving with the 6th Regiment, For example, to shoot, one must first know how to U.S. Marines, in actual conflict with the enemy. With safely handle and sight-in (or “zero”) the weapon. absolute disregard for personal safety, ever conscious and mindful of the suffering fallen, Surg. Boone, To move, one must know how to establish his or leaving the shelter of a ravine, went forward onto her position and navigate. According to the tenets of the open field where there was no protection and de- the Geneva Conventions, medical personnel are not spite the extreme enemy fire of all calibers, through combatants and are entitled to certain protections a heavy mist of gas, applied dressings and first aid (so long as they are working exclusively in a medical to wounded marines. This occurred southeast of Vi- role and not participating in acts harmful to the en- erzy, near the cemetery, and on the road south from emy).1–3 However, the vast majority of armed conflicts that town. When the dressings and supplies had been the United States has engaged in since World War II exhausted, he went through a heavy barrage of large- include combatants that do not adhere to the Geneva caliber shells, both high explosive and gas, to replen- ish these supplies, returning quickly with a sidecar Conventions. Thus, the physician cannot assume the load, and administered them in saving the lives of the protections of Geneva Conventions status and must wounded. A second trip, under the same conditions be prepared to be treated as a combatant. and for the same purpose, was made by Surg. Boone As a rule, units are willing to facilitate teaching their later that day.4 assigned physician combat skills if he or she shows an interest. It is beneficial to the unit to have a physician In addition to earning the Medal of Honor, Boone who is independent and competent in a combat zone; a was awarded the Army’s Distinguished Service Cross, physician cannot execute the critical medical role if he multiple Silver Stars, and many other awards, making or she is lost or dead. Deployable medical units have him among the most decorated military physicians a cadre with the responsibility to teach basic combat in history.5 With one of the most remarkable and dis- skills to their medical providers. In other units, a phy- tinguished careers in the history of the US military, sician with initiative and persistence will find trained Vice Admiral Boone demonstrated preparedness and personnel and resources to help. Learning combat readiness that led to courage and success when it re- skills is experiential; reading it in a book, seeing it on ally counted. He is an excellent example for all military a video, or being told what to do will not suffice. The physicians.

THE PROBLEM AND NEED FOR TRAINING

With the exception of Special Operations units, no for these physicians to regularly train in combat skills service officially requires physicians to become profi- with their unit members is expected. In all other units, cient or familiar with any combat skills, and military pursuing training in these skills is the physician’s re- units often do not place any demands on the physician sponsibility; it is often not provided by the unit. outside of medical tasks beyond the minimum military As a result, physicians may receive only a half-day requirements. Special Operations units expect their of familiarization with a pistol, while the remainder physicians to have (from prior service) or to develop of readiness preparation involves updating medical/ the ability to handle themselves in rapidly changing dental/immunizations requirements; ensuring their situations, including combat. Thus, the opportunity security clearance and ISOPREP (isolated personnel

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report, a secure individual profile on file in case a Advanced Trauma Life Support or Advanced Cardiac person must be rescued and their identity verified) is Life Support standards. However, medics will look up to date; and making sure various computer-based to the unit physician for medical training, validation, training is current. These kinds of activities, although and mentorship. The physician must have an in-depth important for deployment readiness, do not constitute understanding of TCCC principles and techniques tactical field skills preparation or adequately prepare to be able to communicate in a common language the physician for working in a combat environment. and utilize the same treatment algorithms when it is The unit may facilitate scheduling combat arms train- necessary to provide care under fire. Physicians need ing but not offer extra training such as combatives, land to train medics in TCCC-recommended medications navigation, or small team tactics. for pain control and wound prophylaxis; medics have Likewise, training as a physician does not include the know-how to administer medications but may preparation for combat field medicine. Experienced not fully understand how they work or when certain combat-proven medics often know more about saving medications may be better than another. It is important lives of wounded warfighters in the field than physi- to practice how to care for casualties out of an aid bag, cians. Medics are experts in Tactical Combat Casualty including in the dark. Practice improves performance Care (TCCC),6 and it behooves the military physician to not just individually, but also collectively between the learn and be able to execute these standards as well as tactical physician and medic.

SHOOT

Weapons Training provides first-hand experience with the occupational noise exposure warfighters face, which emphasizes the In a combat zone, the physician is usually assigned importance of advocating for the funding and enforce- a weapon, most often a pistol (M9) or possibly a rifle ment of appropriate hearing protection. In addition, (M4). Even under almost all theater-established rules shooting can be a significant source of occupational of engagement, medical personnel never lose the right lead exposure, especially for personnel who routinely to self-defense according to the Geneva Conventions. shoot in indoor ranges. The unit physician should Rules of engagement vary with the threat level and track shooting-associated occupational concerns such phase of combat operations. For example, in the initial as proper ventilation in firing ranges, hand-washing assault phase of a combat operation, a soldier may immediately after firing range operations, and blood legally shoot any enemy holding a weapon, whereas lead level monitoring in populations that routinely fire in the stabilization phase of combat operations, the assigned weapons. In addition, going to the range and soldier may have to wait until that same enemy makes firing weapons once or twice a year provides physi- a threatening gesture before shots can be fired. By the cians an opportunity to get to know their patients in Geneva Conventions, however, as medical personnel, a nonclinical setting. physicians can shoot only if threatened and there is a The ideal time to learn how to safely handle and need to protect their own life or the life of patients.7 employ firearms is before deployment; during deploy- In such cases, deadly force may be used. It is vitally ment is too late to become comfortable with a weapon. important to understand such rules of engagement Weapons may be assigned because of an increased within the confines of the Geneva Conventions, and threat level, and there is no time to become proficient medical personnel must be ready to utilize deadly with a weapon once an assault starts. Hospitals and force when appropriate in order to be a force multi- aid stations are notoriously soft targets that enemies plier for the unit. Physicians should not be the cause will exploit if given a chance. of further casualties because of a lack of resolve or Physicians should seek weapons training and work understanding of their role in combat. through the chain of command to get more time on the There are reasons to be familiar with weapons and firing range. Depending on the military service (Army, shooting other than self-defense and protecting pa- Navy, Marines, or Air Force) and the particular type of tients. Chances are, firing a weapon is an activity at unit the physician is assigned to (conventional forces least some members of the unit do regularly as part of vs special operations), the method and ease of obtain- their job, and understanding the forces imparted to the ing time on the shooting range will differ. However, body, both from recoil and from shooting positions, all physicians should respect and be friendly with unit will help the physician more appropriately profile noncommissioned officers, who can be immensely (impose medical duty limitations) to protect these helpful and have established lines of communication patients while recovering from injury. Shooting also and trust with other units and agencies involved with

155 Fundamentals of Military Medicine scheduling training (see Chapter 12, Enlisted Service ger squeeze (trigger “press”), and aiming in different Members, for a more detailed explanation of the role firing positions (prone, sitting, kneeling, firing around of the enlisted corps). If the extra training cannot get barricades). In addition, magazine changes with empty scheduled or authorized through regular channels, magazines can be practiced. physicians should take the initiative to go to a local Sighting in or “zeroing” a weapon is the critical shooting range, many of which are within driving process of adjusting the weapon sights (iron sights or distance from most military bases and can provide optics) so that the fired round impacts the intended weapons and training in the fundamentals. Civilian target. The initial sight in or “zero” should be at close 9-mm pistols are similar to those most likely issued range (15 m or less for a pistol, 25 m for a rifle). Once to officers during deployments. the sights are grossly adjusted and there is a consis- This chapter is not a resource on weapons safety. tent shot grouping at close range, the process should However, a few foundational concepts that should be be repeated at actual engagement ranges to further understood by anyone who works around firearms are fine-tune the sighting (25 m for pistol, 200+ m for rifle). provided here. Regardless of whether one is a novice Additionally, shooting should be practiced while or expert with firearms, the following rules mustnever wearing assigned protective equipment. Firing a be modified or broken: weapon while wearing a helmet and body armor is much different than without: sling length, holster 1. Always treat the weapon as if it was loaded, position, and shooting positions will change. Ear and and do not rely on a mechanical safety to keep eye protection must also be worn, and eye protection the weapon safe. may slightly alter the sight picture and negatively 2. Never point a weapon at anything other than affect accuracy if the user is not looking through the the intended target. center of the lenses. 3. Keep fingers off the trigger until ready to Physicians should clean their own weapon no mat- shoot. ter what their rank or how busy their schedule is; this 4. Be sure of the target, what is around it, in responsibility should never be delegated. There is front of it, and behind it. much to be learned about a firearm from the cleaning process, and doing so will earn respect from soldiers Additionally, every time a firearm is held, the who see this as a duty that should never be shirked. weapon must be inspected: is there a loaded magazine or a round of ammunition in the chamber (the chamber Combatives is where the round of ammunition lines up with the barrel for firing)? Physicians must be familiar with Combatives (or hand-to-hand fighting) training is this procedure before accepting a weapon. There must widely available on most military bases. Understand- be absolute certainty about the status of any weapon ing the forces and stress on personnel undergoing com- being held; a round of ammunition negligently fired batives training is important for the military physician can never be taken back, and the consequences can be assigned to a combat unit. The best way to understand permanent and tragic. There is never an acceptable the forces involved in combatives training is by first- excuse for a negligent discharge of a weapon. hand experience. During sparring, a “preposterone Although much can be learned about weapons effect” can occur, in which the intensity increases to handling and shooting from books and videos, it is the point where sparring partners end up hurting each a physical skill that must be executed to truly learn other. A military physician who works with combat- it. Dry firing, the act of going through the motions of ives instructors is able to effectively collaborate and shooting with a confirmed (and reconfirmed) empty better protect unit members from unnecessary injury weapon, does not hurt the weapon and is an excellent while undergoing this training. A physician does not way to practice employing a firearm (the shot must need to become an expert fighter, but learning the basic still be performed in a safe direction). Specifically, skills helps the physician understand possible injuries dry firing can provide practice grasping the handle, from combatives, provides a modicum of physical using the weapons sights, establishing a smooth trig- confidence, and can be fun.

MOVE

Principles of Navigation This skill is still taught for several reasons, including the possibility of losing GPS access when fighting an It is critical to learn navigation by map and com- enemy with advanced capabilities. For a decade, the pass even in the global positioning system (GPS) era. Navy had stopped teaching midshipmen celestial

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navigation, but as of 2016 it is back in the curriculum not usually required to get these licenses. However, because of a reasonable assessment of the threat and if the base is located in a cold climate, there may be potential vulnerability of US satellites.8 Navigating mandatory cold weather driving and vehicle main- with a map and compass is a basic soldiering skill, tenance training; if overseas, there may be specific is reasonably easy to learn, and provides confidence driving license testing requirements. Operational units when moving through rural areas for training or com- and any military facility with a motor pool (a location bat. It is a key step for many military schools, such as where military vehicles are stored and maintained) Ranger training, and in all combat arms training. have procedures for qualifying and licensing military There are many good books on navigation, both personnel to drive military vehicles. Although guide- military and civilian. Navigation training does not lines establish priority to receive training, there are require any special equipment, and is available at local always opportunities to receive training by request orienteering or outdoor clubs if efforts to find military (a recurring theme for most of the skills described in training come up short. Physicians should make every this chapter, which allow physicians to broaden skill effort to participate when their unit conducts this train- sets and function in multiple capacities to be a force ing, including land navigation at night, which can be multiplier in combat settings). much more difficult and requires practice. Knowing how to read a contour map is also important; however, Convoy Operations it is not as critical as being able to accurately locate oneself on a standard map. Medical personnel do not usually run convoy opera- Nautical charts and maps use the universal system tions but may need to travel with a convoy to other of latitude and longitude to describe a location on the locations within a combat zone. Convoys should not globe. All maps are based on a model of the earth’s be joined without preparation. All participants must sphere called a “datum,” which incorporates a grid be prepared to respond to an attack, which requires system, called a “projection,” which mathematically practice. The convoy leader (who may not be the senior transforms the 3-dimensional sphere to a 2-dimension- person in the convoy) should explain and rehearse the al map. Worldwide, there are many datum choices. Ex- proper immediate response to an improvised explosive amples of common datums for US maps and charts are device (IED) and other types of ambush. Unit medics WGS-84 or NAD–83. When using coordinate systems and physicians must know exactly where medical such as latitude and longitude, or grid coordinates, gear (litter, burn blanket, other blankets, additional it is necessary to know which datum the coordinates aid bags, etc) is located within the convoy and inspect are based on. The error of the same coordinates in it prior to moving. two different datums can be substantial, on the order Convoy participants should also study the route to of kilometers. be taken; note significant terrain features (eg, which A geocoding system founded in 2013, called “What- side of the big bend in the Tigris River the embassy 3words,” has assigned three dictionary words to every is on); keep in mind the safest direction to travel in 3 × 3 m2 of the globe.9 It is a simple way to locate any case of separation; and memorize any rendezvous place on the planet; for example, a square at the foot points along the route. Many convoys carry a track- of the Statue of Liberty is exactly described by the ing device that sends a GPS signal to a secure satellite, words “planet.inches.most.” Three words are much which can be tracked by secure ground stations. Some easier to remember than a 10-character alphanumeric, of these tracking devices have an emergency switch; and much less likely to result in a transcription error. all participants should learn how this device works The three words can be translated into a GPS location and how to activate any emergency beacon functions. (and vice versa), as well as driving instructions, with The physician should know the MEDEVAC (medical simple, free phone applications. The system is already evacuation) radio frequency, the frequency to the tacti- being used in over 170 countries and its use is growing, cal operations center, and how to work the radio in the especially in the developing world where many exist- vehicle (see Communicate, below). Participants should ing roads are not named or posted. While not currently know about any other countermeasures. used by the US military, it could be especially useful Passengers should sit in the back seat on the driver’s in large refugee camps without street addresses, or side in countries that drive on the right side of the in humanitarian aid and disaster response missions. road (away from the side of the road where bombs might be buried), and wear proper protective equip- Driving Military Vehicles ment (helmet, body armor, eye protection). Electronic noise-cancelling hearing protection, if available, is also Driver training and getting licensed for driving beneficial because even a single unprotected exposure military vehicles is fairly easy, although physicians are to a very loud sound, such as a roadside IED detona-

157 Fundamentals of Military Medicine tion, can permanently damage hearing. This equip- 2. The second layer is the “combat load,” con- ment blocks loud and harmful sounds, such as gunfire sisting of items critical to the performance of or explosions, while allowing the wearer to hear faint the mission. It usually consists of ammuni- sounds to maintain situational awareness. tion, water, personal radio (if assigned), night Passengers, even if qualified on the weapon, should optic device (if assigned), and in the case of stay out of the gun turret. Despite how nice it may feel the unit physician, the aid bag. to get fresh air and how exciting it may be to fire such 3. The final layer is the sustainment load, car- a weapon, this is an unnecessary risk that puts the en- ried in a rucksack and consisting of items tire unit in jeopardy. In addition, filling such a combat needed for the length of the mission. For a role when not absolutely necessary jeopardizes one’s multiday mission, these items include ad- Geneva Convention status and may do irreparable ditional water, food, additional ammunition, harm to the mission due to unfavorable press coverage. batteries, climate-appropriate clothing and When moving around a semi-permissive environ- foul-weather gear, sleeping bag with ground ment (one in which the host nation has only partial ef- pad, hygiene items, and other items as the fective control of the territory) in civilian-style vehicles, mission dictates. soldiers should try to blend in as much as possible (eg, if the locals do not wear sunglasses, anyone wearing The IFAK should be carried at all times in the loca- them would be marked as a foreigner). tion specified by the unit’s standard operating procedure. This allows everyone on the convoy to know Personal Equipment and Moving where to rapidly find the critical first aid supplies if a soldier is wounded. Common practice is to use sup- The concept of “layering” personal combat equip- plies from the wounded soldier’s IFAK first, and then ment must be understood. There are three basic layers use supplies from other IFAKs only if needed. of personal equipment: If movement occurs in the dark of night, helmet- mountable night optic devices (NODs) should be used 1. The base layer is always worn and consists if available (the term “night vision goggles” should of the uniform itself; protective equipment not be used because many common NODs, such as the (body armor, helmet, eye protection, ear PVS-14, are monocular and not a goggle). If a NOD protection, gloves, etc); the Individual First is available, the correct mount and bracket to attach Aid Kit (IFAK), which includes bandaging, the NOD to the assigned helmet must be confirmed tourniquets, analgesics, and antibiotics; and the physician will need to practice with it. In case critical survival items kept in pockets (map, the physician is the only one uninjured to drive the compass, knife, red-lens LED headlamp, fire vehicle, he or she should also practice driving with starter, etc); and assigned weapon. NODs.

COMMUNICATE

Understanding the basics of military communica- • Contingency–cell phones tions is a foundational skill that all military members • Emergency–send a runner should grasp, including physicians. This skill is needed to call for a MEDEVAC, to call for help, and to talk with It is vitally important that all members of a unit, the search and rescue aircraft when forced to escape and including the physician, be familiar with the plan and evade. Communications equipment is often encrypted, know the proper frequencies and numbers necessary so it is important to have a basic understanding of to use the equipment. The unit cannot rely on just a handling cryptologic material. All communications few members who are considered responsible for the methods can fail, sometimes at critical times, so famil- radio. The unit physician may have to use the radio iarity with the communications plan that outlines the because the warfighters who are supposed to use it are multiple redundant communications systems is useful. either incapacitated or actively engaging the enemy. The “PACE” (Primary, Alternate, Contingency, Military radios are called transceivers, which is a Emergency) mnemonic is often used in military com- combination of a transmitter (which sends signals) and munications plans; for example: a receiver (which reads incoming signals). Transceivers use different frequencies of electromagnetic waves, and • Primary–VHF (very high frequency) military these frequencies are artificially grouped into named radio bandwidths. The details on the various bandwidths • Alternate–satellite phone are listed in Exhibit 10-1.

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EXHIBIT 10-1 RADIO FREQUENCY TYPES

• UHF (ultra high frequency), 300–3,000 MHz. Used for line-of-sight communication with aircraft and for satellite communications. Because of its relatively dense frequency, UHF can carry a relatively large amount of data for a given bandwidth. UHF has good short-range penetration and is good for communications inside buildings and structures; however, it has limited range for most ground-to-ground communications and is rarely used for this purpose. Obstacles on the ground more rapidly attenuate UHF than lower frequencies. • VHF (very high frequency), 30–300 MHz. In the military, VHF is used primarily in ground-to-ground communications, but may be used in military aircraft to communicate with ground-based troops. VHF is the same range used by commercial radio stations. The voice (or data) information is embedded in a carrier frequency by a technique called “frequency modulation,” or FM. As a result, VHF communications are often referred to by the alphanumeric term “Fox Mike” (for FM). Military radios may use a frequency-hopping capability to attempt to foil an enemy from either listening in or using direction-finding equipment to locate the unit. Frequency-hopping radios in communication with each other must be synchronized on the same algorithm (otherwise, communications are impossible); in an emergency, synchronization can be complicated if the user is not familiar with the radio’s operation. Operators should know how to take the radio out of frequency hopping mode and establish communications (“get up”) on the MEDEVAC frequency. VHF is generally useful for line-of-sight communications with a maximum range roughly determined by the height of the antenna, curvature of the earth, and power output, with a common maximum range of 30 miles in clear terrain, and a minimum range of 1 mile or less in dense jungle. • HF (high frequency), 3–30 MHz. Also known as “shortwave radio,” HF used to be a staple of military long-range communications because it has a potential global reach, but it has largely been replaced by satellite communications. When higher-frequency transmissions reach the ionosphere, they keep going (which is why UHF is useful to communicate with satellites). Under the right circumstances, HF waves could be refracted (bent) by the ionosphere back to earth, potentially sending the signal around the world. HF communications are heavily dependent on time of day, frequency, atmospheric and sun spot activity, antenna configuration, and power output of the transmitter. These factors make HF communications less reliable for military communications. However, the vulnerability of satellites to electro-magnetic pulse radiation may bring HF communications back into more common use in the military. Like all communications, HF signals can be encrypted, and they can be sent in dense brief bursts of data. “Burst” transmissions (versus “voice transmissions”) dramatically reduce the time a potential enemy has to use direction-finding equipment.

“Radio discipline” is exemplified by clear and suc- line” in checklist fashion helps ensure all necessary cinct transmissions, sent only when appropriate. Radio items, such as hoists, other extraction equipment, or discipline implies using the assigned radio channel (or specific medical equipment are requested (memorizing “net”) only when there is something important to say, the 9-line MEDEVAC request should not be relied on). and interfering with an ongoing transmission only in Cryptologic material encodes and decodes commu- an emergency. If a unit is under attack, communication nications. Because radios are designed to talk to each often starts with a phrase such as, “emergency, troops other, they all run the same codes (or “fill”) on any given in contact.” This tells everyone on the radio network day. This means the loss or misplacement of cryptologic cease nonemergency communication and prepare to material renders the entire global US military commu- provide assistance. If those listening are unable to help, nications system vulnerable. Mishandling cryptologic they remain quiet and off the network while others materials is a significant mistake with serious and last- who are able to assist (eg, a reaction force, close air ing consequences. It is absolutely imperative that lost support, or MEDEVAC personnel) can communicate. or suspected loss of cryptologic material is immediately Radio discipline also means knowing when to use reported to the chain of command. Proper handling of standardized formats, such as calling in MEDEVAC cryptologic material is similar to handling narcotics: or close air support. Exhibit 10-2 is an example of a they must be kept in an approved safe and exactly standard 9-line MEDEVAC format. A 9-line request accounted for on a permanent record. Most military card should be carried by all service members in a radios have encryption capability. How to “zero-out” or combat zone to use as reference. Executing the request “dump” (permanently delete) the cryptologic material properly will prevent unnecessary delays that could on the radio to prevent it from falling into enemy hands lead to worsened patient outcomes. Utilizing the “9- is another skill the physician should learn.

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Portable satellite communications may be conducted EXHIBIT 10-2 with an encrypted UHF (ultra-high frequency) radio 9-LINE MEDEVAC REQUEST transceiver and a small directional antenna. The antenna must be pointed roughly at the satellite’s location in space, meaning the antenna is pointed on the correct Line 1. Location of the pick-up site. compass bearing and azimuth (angle above the ground, Line 2. Radio frequency, call sign, and suffix. with 90° pointing straight up and 0° pointing at the Line 3. Number of patients by precedence. horizon). Most communications satellites used by the A: Urgent military are in geosynchronous orbits, meaning they B: Urgent surgical stay in the same part of the sky relative to the earth as C: Priority it spins. These satellites may only be available during D: Routine certain time windows. The radio must be on the correctly assigned frequencies for sending and receiving, E: Convenience with the correct cryptologic material fill. With the right Line 4. Special equipment required. frequency, fill, and time period, satellite communica- A: None tions are usually the most reliable form of long-distance B: Hoist communication. “Long-distance” is defined as any C: Extraction equipment distance longer than ground-based VHF radios can D: Ventilator reliably communicate. One potential disadvantage of Line 5. Number of patients. satellite communications is that unless the unit also has a specialized antenna for use on a moving vehicle, the A: Litter vehicle must stop so that the antenna can be pointed B: Ambulatory in the correct direction and elevation to communicate. Line 6. Security at pick-up site.* Relying on mobile phones as the primary or only N: No enemy troops in area means of communication is a poor plan. Even if it P: Possible enemy troops in area (ap- works well in one location on a particular day, it may proach with caution) not work when and where it is needed. When a mo- E: Enemy troops in area (approach with bile phone must be used, do not use a personal phone caution) unless it is a true emergency (and part of the PACE X: Enemy troops in area (armed escort plan as described above). A mobile phone may work required) in one country but fail when the border is crossed into *In peacetime, list instead number and types of wounds, a neighboring country. Country code dialing prefixes injuries, and illnesses. for all surrounding countries in the area of operation Line 7. Method of marking pick-up site. should be known. Other practical tips that are easy to forget include having the correct plug adapters for A: Panels charging cables and carrying extra batteries or power B: Pyrotechnic signal supplies to recharge batteries. In many developing C: Smoke signal countries, mobile phone networks are unreliable dur- D: None ing high-use time periods, and dead zones are common E: Other and large. If a voice phone call does not go through, Line 8. Patient nationality and status. sometimes text messages will go through. A: US Military Satellite phones, however, do not rely on local cel- lular networks. They directly communicate with a B: US Civilian constellation of satellites that provide global coverage. C: Non-US Military They are a reasonable alternative plan for communica- D: Non-US Civilian tions, but must be routinely tested in locations where E: Enemy Prisoner of War they may be needed. Satellite phones that have not Line 9. NBC contamination.* been tested cannot be relied on; they may work inter- N: Nuclear mittently; and batteries may die at inopportune times. Units should also ensure there is time on the service B: Biological contract to cover the period of anticipated use plus at C: Chemical least 2 months. No matter the type of communications *In peacetime, instead provide terrain description of device being used, if it is not encrypted, users must not pick-up site. talk about, or around, classified topics.

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ADDITIONAL OPERATIONAL MEDICAL TRAINING

In addition to being a physician assigned to a combat non-work situations. The more time an FS spends with unit or special operations unit, there are unique op- the unit, the more trust and respect he or she will earn, erational medical billets that include training as a flight and the FS’s ability to effectively care for the unit and surgeon (FS) or a dive medical officer (DMO) in the Army enhance mission-readiness will be multiplied. or as an undersea medical officer (UMO) in the Navy. Dive Medicine Flight Medicine Army DMOs and Navy UMOs are also special- Becoming an FS takes between 6 weeks (Army and ized operational medical billets. Both are trained as Air Force) and 6 months (Navy). The reason the Navy’s military divers, which is academically and physically program is so much longer is because the Navy FS very rigorous. A DMO is limited to the care of military training program includes actual flight training up to undersea divers, while the UMO is also responsible for the point of solo flight, while the Army and Air Force the medical requirements and medical hazards unique programs provide only orientation and familiarization to submariners. Training to become a DMO takes 9 flights, not individual flight training. The term “sur- weeks and is conducted by the Navy. Training to be- geon” is a holdover from the days when all military come a UMO takes a total of 22 weeks in three phases.10 physicians were considered “field surgeons.” FSs learn Both DMOs and UMOs are experts in the recognition the physiological effects of flight and atmosphere as well and treatment of diving casualties, including the use as the medical administrative requirements for safely of recompression protocols in hyperbaric chambers. providing medical care to aviation personnel. FSs are required to fly as a crew member a minimum of 4 hours Airborne a month while in flight status in order to better understand the patient population and their occupational haz- Some assignments include an opportunity to attend ards. Similar to a unit physician assigned to an airborne airborne training. Physicians assigned to an airborne unit unit who is expected to have parachuting experience, an are expected to have parachute wings. If they are not al- FS is expected to understand the nuances of the world ready earned, the unit will send the physician to airborne of military aviation. FSs also perform medical services training. Again, this training is a fairly intense shared for military freefall parachute jumpers and drone pilots. experience and an opportunity to build rapport, which is A major challenge faced by the FS is balancing the critical to earning the unit’s trust and respect, and being needs and requests of individual aviators with the an effective unit physician. Experience with parachuting needs of the team and mission. An FS must maintain helps a physician understand the unit’s various medical confidentiality with individual aviators, but must also issues and assess its overall health and readiness. have the authority to ground any aviators when their medical condition may compromise flight safety or Survival, Evasion, Resistance, Escape mission success. This may involve being available to the flying unit at all times for consultation, as well as Training in survival, evasion, resistance, and escape coordinating medical care with specialists in a timely (SERE) is vital for military physicians. SERE training manner to get the grounded aviator back to flying sta- teaches vital strategies for staying alive if captured tus as soon as possible. Being part of the team, while by the enemy. When groups of service members are maintaining a proper professionalism to make tough captured, the captors will exploit the weakest link, and calls, can be difficult. These situations can be managed those who have not had SERE training are more likely most effectively when the unit’s aviation personnel to succumb. The training is unpleasant at times, but the know and trust their FS as a person and as a physician. payoff is more than worth the temporary discomfort. This rapport comes most easily if the FS regularly flies If at all possible, enrollment in SERE training should with the crew and spends time with the unit, even in be pursued by military medical providers.

OTHER CONSIDERATIONS

Military Bearing appearance. Despite other qualifications, physicians who do not meet weight standards or wear the uniform In operational units, active duty service members properly lose credibility. Simple keys to success include judge the physician by his or her military bearing and staying physically fit, wearing the uniform correctly,

161 Fundamentals of Military Medicine keeping hair in regulation, and learning how to give a place. To be effective in a combat environment and crisp salute. These simple actions will pay dividends thus a force multiplier, the physician must understand in training opportunities and building respect. the mission to anticipate the medical threats to the unit. Thus, the physician should request operational Medical Evacuation and Mass Casualty Planning briefings from the operations section of the unit to and Training develop a proper situational awareness. If possible, the physician should see where the troops are living, Regardless of whether the physician arrives at a new especially if they are remotely located. Food safety or established deployment location, there are several must be assessed (actually a military public health of- critical tasks he or she must accomplish. MEDEVAC ficer responsibility, but the physician has overlapping plans must be confirmed, clinic supplies must be responsibilities), as well as water safety, sanitation, and checked, a mass casualty (MASCAL) plan must be force protection measures such as ensuring warfighters ready, and the casualty collection points must be are taking proper precautions to protect themselves stocked and ready for use. The physician must never from vector-borne illnesses (eg, antimalarials). The fully rely on anyone else to do these tasks, and should physician is responsible for performing these tasks not rest until they are done. without direction from command. The physician is Within a week or so of arrival, the physician should the subject matter expert and must bring any concerns insist on a full live rehearsal of the MEDEVAC plan. found during these inspections to the unit commander. MASCAL lockers at the casualty collection points should In addition to receiving briefings from opera- be well stocked with TCCC-approved medical supplies. tions, the physician should seek a briefing from the Well-organized plans to triage, mark, and track casual- intelligence section for information about the enemy ties, as well as treat multiple casualties at night in foul situation. Similar to the operational environment, the (or hot) weather is critical. In addition, expansion plans intelligence environment and threats must be under- utilizing buildings of opportunity or putting up addi- stood by the physician, at least in broad strokes. For tional tents must be considered if tactically appropriate. example, understanding how realistic it is for chemical, Reliably receiving medical supplies in a timely man- biological, radiological, nuclear, or explosive (CBRNE) ner can be notoriously difficult in a combat setting, so weapons to be used by the enemy will greatly enhance the physician must understand how medical supplies the physician’s preparations for what kind of casualties (Class VIII) are ordered and how long it takes to receive may be expected. The CBRNE threat is real, and it is them. A good starting plan is to arrive with enough better to be prepared for the worst scenario. Intelligence supplies to last at least twice as long as the typical personnel will help the physician increase situational logistics chain timeframe without resupply. awareness within the confines of security clearances.

Preventive Medicine Time Management

Field sanitation and preventive medicine are vital Although physicians should seek combat training to the health and readiness of the unit. The unit physi- as described in this chapter, their primary duty is to cian oversees unit preventive medicine assets and must be an outstanding physician. The unit physician must ensure that adequate preventive medicine measures be mindful of impressions (eg, if the physician is out are in place. He or she is responsible for maintaining of the clinic too often going to the shooting on the acceptable, approved methods of procuring clean wa- range, it may cause resentment from colleagues who ter, adequate hand-washing stations, vector control may have to cover clinic duties). The unit physician measures, and latrine and shower facilities, both for must learn how to balance personal injury risk from enhancing unit morale and, more importantly, for combat training activities, time outside the clinic, and controlling disease rates. Throughout history, unit maintaining clinical proficiency to perform the primary effectiveness has been harmed more by disease and task as the unit’s medical expert. During training as nonbattle injuries than from conflict-inflicted injuries. well as at deployed locations, the physician should It is vital for the unit physician perform this role ef- be willing to help load pallets, put blast blankets over fectively (see Chapters 16 and 40). windows, help fill sand bags, and perform other unit tasks. In this way other unit members will accept the Operational and Intelligence Briefings physician as a team member, working toward the same mission goals. This earned respect will pay dividends The physician must understand what the unit’s by the warfighters who will look out for their physician objective and mission are and where they will take in ways that cannot be easily articulated.

162 Tactical Field Skills for the Military Physician

SUMMARY

To be an effective military physician and a force officer. During deployment, the physician is ultimately multiplier by supporting the warfighters in the combat responsible for casualties, and even experienced med- unit, medical officers must take the initiative to learn ics will look to them for guidance and leadership, tactical field skills. It is not enough to be a good physi- whether or not the physician has tactical experience. cian. Military physicians must know the warfighters At all times, physicians must prepare for and respond and their mission, and they must learn to shoot, move, to threats to the unit’s health and readiness. To be and communicate effectively. Physicians must balance most effective, they must employ both medical and this training with their primary role as the unit medical tactical training.

REFERENCES

1. Geneva Convention I, articles 24–26.

2. Geneva Convention II, article 36.

3. Geneva Convention IV, article 20.

4. Congressional Medal of Honor Society. Boone, Joel Thompson. http://www.cmohs.org/recipient-detail/2506/boone- joel-thompson.php#. Accessed May 30, 2017.

5. The US Navy Memorial. Joel Thompson Boone. http://navylog.navymemorial.org/boone-joel. Accessed May 30, 2017.

6. Committee on Tactical Combat Casualty Care. PHTLS (Prehospital Trauma Life Support), Military. 8th ed. Burlington, MA: Jones & Bartlett Learning; 2016: 655–850.

7. Geneva Convention I, article 22.

8. Peterson A. Why Naval Academy students are learning to sail by the stars in the first time in a decade. Washington Post. https://www.washingtonpost.com/news/the-switch/wp/2016/02/17/why-naval-academy-students-are-learning- to-sail-by-the-stars-for-the-first-time-in-a-decade/?utm_term=.ebee5a6caea0. Published February 17, 2016. Accessed August 28, 2018.

9. what3words website. https://what3words.com. Accessed August 28, 2018.

10. Navy Medicine Operational Training Center website. http://www.med.navy.mil/sites/nmotc/numi/Pages/default. aspx. Accessed August 28, 2018.

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